Hand Hygiene Interventions adapted from VA-3M



Hand Hygiene Interventions adapted from VA-3M

Six Sigma Project

|Is this already in place? If not, when will it be done? |Who is responsible (include person or organization or both)? |Frequency for checking, re-doing, or updating, as appropriate (suggested). | |

|1. Make changes on the walls and countertops, and in the supply closet |

|Alcohol-Based Hand Rubs: One container per bed and one in the corridor for| | | |

|every 2 beds. (Suggested level for ICUs, establish density for other | | | |

|locations based on VA Directive and local conditions.) | | | |

| | | |(annually) |

|Pocket-Sized Alcohol-Based Hand Rub: Supplied by the hospital and made | | | |

|available to all staff. Consider lanyard or retractable cord for the 2 | | | |

|oz. size. | | |(annually) |

|Antimicrobial Soap: Installed on the wall at sinks in all patient-care | | | |

|areas. | | |(annually) |

|Hand Lotion: Supplied by hospital and made available to all staff. Must | | | |

|be formulated for use in healthcare settings. | | | |

| | | |(annually) |

|Posters: Put in staff-only areas, patient-care areas, and waiting areas as| | | |

|appropriate (different posters are available and designated for use in | | | |

|different areas). Posters and other materials are available at VA’s | | | |

|“Infection: Don’t Pass It On” Website. (URL below) | | | |

| | | |(monthly) |

|Brochure or Sign and Alcohol-Based Hand Rub located together: Installed in| | | |

|waiting areas (patient and visitor) to promote alcohol-based hand rub use,| | | |

|and to inform laypeople that efforts to improve hand hygiene compliance | | | |

|are underway at the hospital and that alcohol-based hand rubs are more | | | |

|effective than soap (see “Infection: Don’t Pass It On” poster # “Hands 31”| | | |

|at publichealth.infectiondont | | | |

|passiton/index_hand.htm). | | | |

| | | | |

| | | |(monthly) |

|2. Actions for Infection Control Professionals, Patient Safety Managers, Quality Managers, Nurses, and Supply personnel |

|Measuring Monthly Volume of Alcohol-Based Hand Rub Used: Establish a | | | |

|system for counting monthly number of large alcohol-based hand rub | | | |

|containers used and convert to total grams used. Normalize data by | | | |

|dividing by patient days. Provide data as grams used per 100 | | | |

|patient-days. | | | |

| | | |(monthly) |

|Measuring Compliance with CDC Hand Hygiene Guideline: Use standardized | | | |

|form developed in Six Sigma project to count hand hygiene opportunities | | | |

|and actions: results in percent compliance for set of observations (400 | | | |

|observations recommended). | | | |

| | | |(annually[1]) |

| “Rotate” Hand Hygiene Posters: Select new posters from “Infection: Don’t | | | |

|Pass It On” set and put into poster holders or other established settings | | | |

|to prevent posters from becoming “invisible.” | | | |

| | | |(monthly) |

|3. Required Policies/Rules/Training/Awareness |

|No Artificial Nails: Direct caregivers cannot wear artificial nails. | | | |

| | | |(annually) |

|Update Annual Infection Control Training: Training materials used in | | | |

|annual training must be updated to be consistent with CDC Guideline, JCAHO| | | |

|National Patient Safety Goal and VA Guidance. | | | |

| | | |(annually) |

|Update Infection Control Training for New Employees: Training materials | | | |

|used in annual training must be updated to be consistent with CDC | | | |

|Guideline, JCAHO National Patient Safety Goal and VA Guidance. | | | |

| | | | |

| | | |(annually) |

|Update Hospital Policy Document on Infection Control: Policy must be | | | |

|updated to be consistent with CDC Guideline, JCAHO National Patient Safety| | | |

|Goal and VA Guidance. | | | |

| | | |(annually) |

|4. Promoting Culture Change |

|Promote “It’s OK to Ask” attitude: Caregivers, visitors, and patient | | | |

|should feel free to ask caregivers if they have cleaned their hands. | | | |

|Staff should be informed of this and efforts to promote this action should| | | |

|be fostered. | | | |

| | | |(ongoing) |

|“It’s OK to Ask” and “Infection: Don’t Pass it On” buttons and posters: | | | |

|Buttons should be available and distributed to staff. Poster that states | | | |

|“Patients and Visitors: It’s OK to Ask health care providers if they have | | | |

|cleaned their hands” should always be in ICU and in other selected | | | |

|locations. | | | |

| | | |(quarterly) |

|5. Agency-level Actions |

|Dedicated Web Page(s): Establish linked VA intranet and internet web pages|Yes |VHA Office of Public| |

|with resources for use by VA hospitals and networks. See | |Health & | |

|vaww.vhaco.phshcg/InfectionDontPassItOn/ | |Environmental | |

|or publichealth.infectiondontpassiton/ and vaww.ncps.med.| |Hazards & VHA | |

|or | |National Center for | |

| | |Patient Safety |(quarterly) |

|National Policy: Develop National VHA Directive on Required Hand Hygiene |Yes |VHA National Center | |

|Practices. See Directive 2005-002 at: vaww1.vhapublications/ and | |for Patient Safety | |

|www1.vhapublications/ | | | |

| | | |(annually) |

|Remind Facility staff to Rotate Posters Monthly: VHA staff to generate an |No (Plan to send one|VHA National Center | |

|email list for monthly use to send reminders to facility staff to rotate |e-mail monthly to |for Patient Safety | |

|the posters on display (selection of poster is not mandated – facilities |VHA ICPs and PSMs) | | |

|can choose the posters they prefer). | | |(monthly, on first |

| | | |Monday) |

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[1] More frequently if alcohol-based hand rub used per 100 pt-days declines significantly or if rate is at an unsatisfactorily low level after interventions.

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